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Wednesday, February 28, 2007

Consumer-Directed Death


Twelve-year-old Deamonte Driver died of a toothache Sunday.

A routine, $80 tooth extraction might have saved him.

If his mother had been insured.

If his family had not lost its Medicaid.

If Medicaid dentists weren't so hard to find.

If his mother hadn't been focused on getting a dentist for his brother, who had six rotted teeth.

By the time Deamonte's own aching tooth got any attention, the bacteria from the abscess had spread to his brain, doctors said. After two operations and more than six weeks of hospital care, the Prince George's County boy died.

Deamonte's death and the ultimate cost of his care, which could total more than $250,000, underscore an often-overlooked concern in the debate over universal health coverage: dental care.

I have no idea what to say. I guess it would be crass to point out that it's avoiding outcomes like these that are the reason to adopt universal health insurance; but then I suppose it was crass to use the Love Canal disaster to enact regulations for toxic waste sites, or to use the Enron scandal to pass new regulations for corporate governance. There was absolutely no reason this boy had to die like this, and if we had a rational health care system that didn't put even basic care out of the reach of millions of Americans, it would not have happened.

This reminds me of an article Malcolm Gladwell wrote a while back on why the American health insurance system, with its "thicket of co-payments and deductibles and utilization reviews," is such a failure. Among health economists, the theory goes that, if you have to pay a substantial portion of your health care costs, you will use health care more efficiently. But:
...when you have to pay for your own health care, does your consumption really become more efficient? In the late nineteen-seventies, the RAND Corporation did an extensive study on the question, randomly assigning families to health plans with co-payment levels at zero per cent, twenty-five per cent, fifty per cent, or ninety-five per cent, up to six thousand dollars. As you might expect, the more that people were asked to chip in for their health care the less care they used. The problem was that they cut back equally on both frivolous care and useful care. Poor people in the high-deductible group with hypertension, for instance, didn't do nearly as good a job of controlling their blood pressure as those in other groups, resulting in a ten-per-cent increase in the likelihood of death. As a recent Commonwealth Fund study concluded, cost sharing is "a blunt instrument." Of course it is: how should the average consumer be expected to know beforehand what care is frivolous and what care is useful? I just went to the dermatologist to get moles checked for skin cancer. If I had had to pay a hundred per cent, or even fifty per cent, of the cost of the visit, I might not have gone. Would that have been a wise decision? I have no idea. But if one of those moles really is cancerous, that simple, inexpensive visit could save the health-care system tens of thousands of dollars (not to mention saving me a great deal of heartbreak). The focus on moral hazard suggests that the changes we make in our behavior when we have insurance are nearly always wasteful. Yet, when it comes to health care, many of the things we do only because we have insurance—like getting our moles checked, or getting our teeth cleaned regularly, or getting a mammogram or engaging in other routine preventive care—are anything but wasteful and inefficient. In fact, they are behaviors that could end up saving the health-care system a good deal of money. (Emphases added.)
This is why Health Savings Accounts, so favored by the Bush administration, are so wrongheaded: having a high-deductible plan doesn't necessarily make you more cost-effective in your health care decisions, and the people who run up the highest health care bills -- usually people with chronic illnesses -- are going to bust through that deductible anyway. As much as some on the Right would like to make the health care system more like a "free market," the evidence suggests that it causes more problems than it solves.


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